European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium

Anesthetic Management of Elderly Patients With Down Syndrome: A Case Report

In 1930, the life expectancy of patients with Down syndrome was about 10 years; today, their life expectancy is more than 60 years. With aging, there is an increased need for anesthesia and surgery. There is, however, no published information regarding the anesthetic management of older adults with Down syndrome. In this report, we described the anesthetic management of a 50-year-old woman with Down syndrome undergoing major cervical spine surgery. Components of the anesthetic that we thought would be difficult such as intravenous line placement and endotracheal intubation were accomplished without difficulty. Despite our best efforts, our patient nevertheless experienced both emergence delirium and postoperative vomiting. We advocate that physicians, advanced practice providers, and registered nurses be aware of the unique perianesthesia needs of older patients with Down syndrome.

[Perioperative management of polymedication in geriatric patients: risk reduction and coordination with the family practitioner]

The increasing proportion of older and polymorbid people in the population also means an increase in polymedication and its risks. This places new and complex demands on the interdisciplinary and transsectoral collaboration. The preoperative, perioperative and postoperative management of polymedication is described in the article with respect to frequent risks and the chances of a systematic exchange of information. The establishment of an interdisciplinary admission routine in departments of surgery and communication with the family practitioner is crucial for patient safety.

Surgery/Anesthesia disturbs mitochondrial fission/fusion dynamics in the brain of aged mice with postoperative delirium

Postoperative delirium (POD) is a common complication following surgery and anesthesia (Surgery/Anesthesia). Mitochondrial dysfunction, which is demonstrated by energy deficits and excessively activated oxidative stress, has been reported to contribute to POD. The dynamic balance between mitochondrial fusion and fission processes is critical in regulating mitochondrial function. However, the impact of Surgery/Anesthesia on mitochondrial fusion/fission dynamics remains unclear. Here, we evaluate the effects of laparotomy under 1.4% isoflurane anesthesia for 2 hours on mitochondrial fission/fusion dynamics in the brain of aged mice. Mice in Surgery/Anesthesia group showed unbalanced fission/fusion dynamics, with decreased DISC1 expression and increased expression of Drp1 and Mfn2 in the mitochondrial fraction, leading to excessive mitochondrial fission and disturbed mitochondrial morphogenesis in the hippocampus and prefrontal cortex. In addition, surgical mice presented mitochondrial dysfunction, demonstrated by abnormally activated oxidative stress (increased ROS level, decreased SOD level) and energy deficits (decreased levels of ATP and MMP). Surgery/Anesthesia also decreased the expression of neuronal/synaptic plasticity-related proteins such as PSD-95 and BDNF. Furthermore, Surgery/Anesthesia induced delirium-like behavior in aged mice. In conclusion, Surgery/Anesthesia disturbed mitochondrial fission/fusion dynamics and then impaired mitochondrial function in the brain of aged mice; these effects may be involved in the underlying mechanism of POD.

Randomized clinical trial of intraoperative dexmedetomidine to prevent delirium in the elderly undergoing major non-cardiac surgery

Background

Delirium is common in elderly patients after surgery and is associated with poor outcomes. This study aimed to investigate the impact of intraoperative dexmedetomidine on the incidence of delirium in elderly patients undergoing major surgery.

Methods

This was a randomized double-blind placebo-controlled trial. Elderly patients (aged 60 years or more) scheduled to undergo major non-cardiac surgery were randomized into two groups. Patients in the intervention group received a loading dose of dexmedetomidine 0·6 μg/kg 10 min before induction of anaesthesia followed by a continuous infusion (0·5 μg per kg per h) until 1 h before the end of surgery. Patients in the control group received volume-matched normal saline in the same schedule. The primary outcome was the incidence of delirium during the first 5 days after surgery. Delirium was assessed with the Confusion Assessment Method (CAM) for non-ventilated patients and CAM for the Intensive Care Unit for ventilated patients.

Results

In total, 309 patients who received dexmedetomidine and 310 control patients were included in the intention-to-treat analysis. The incidence of delirium within 5 days of surgery was lower with dexmedetomidine treatment: 5·5 per cent (17 of 309) versus 10·3 per cent (32 of 310) in the control group (relative risk (RR) 0·53, 95 per cent c.i. 0·30 to 0·94; P = 0·026). The overall incidence of complications at 30 days was also lower after dexmedetomidine (19·4 per cent (60 of 309) versus 26·1 per cent (81 of 310) for controls; RR 0·74, 0·55 to 0·99, P = 0·047).

Conclusion

Intraoperative dexmedetomidine halved the risk of delirium in the elderly after major non-cardiac surgery. Registration number: ChiCTR-IPR-15007654 (www.chictr.org.cn).

Proteomic Analysis of Preoperative CSF Reveals Risk Biomarkers of Postoperative Delirium

Objective: To analyze the proteome of preoperative cerebrospinal fluid (CSF) in older orthopedic patients with or without postoperative delirium (POD) using untargeted proteomics. Methods: A prospective cohort study was conducted. Eighty hip fracture patients aged ≥65 years were recruited. After successful spinal anesthesia, CSF was collected. The patients were divided into POD and No-POD groups based on the Confusion Assessment Method, and patients with POD were graded using the Memorial Delirium Assessment Scale (MDAS). Thirty No-POD patients were matched to 10 POD patients by age (±2 years) and Mini-Mental State Examination score (±2 scores). Label-free proteomic analysis was performed using a liquid chromatography coupled to mass spectrometry (LC-MS) workflow. Validation was performed using mass-spectrometry-based parallel reaction monitoring (PRM) for the 30 No-POD and 10 POD patients, as well as for an additional 5 POD patients. Bioinformatics were used to investigate possible relevant pathological mechanisms. Results: The incidence of POD in older orthopedic patients was 18.8% in our cohort of 80 patients. Proteomics results revealed 63 dysregulated CSF proteins, and PRM analysis validated these results. The preoperative CSF levels of both V-set and transmembrane domain-containing protein 2B (VSTM2B) and coagulation factor V (FA5) were positively correlated with MDAS scores on postoperative day 1 (r > 0.8, p < 0.05). Bioinformatic analysis revealed that several nervous-system-related pathways are relevant to POD development. Conclusion: We identified and validated several novel CSF proteins that are dysregulated in POD, and revealed several pathways that are relevant to POD development. Our results not only provide risk biomarkers for POD, but also give clues for further investigations into the pathological mechanisms of delirium. Clinical trial registration: This study was registered in the Chinese Clinical Trial Registry (ChiCTR1900021533).

Pre-operative femoral nerve block for hip fracture-A systematic review with meta-analysis

BACKGROUND

Pre-operative pain management of hip fracture patients is complex. Femoral nerve block (FNB) is used for hip fractures to reduce pain and demand for systematic analgesia. The objective of the study was to systematically investigate the efficacy of single-shot FNB for hip fracture patients.

METHODS

Five databases were searched from inception until 8 May 2019. We included randomized controlled trials (RCT's) assessing pain relief in patients with hip fractures. Intervention was pre-operative FNB compared to any systemic analgesic (eg opioids, non-steroidal anti-inflammatory drugs or paracetamol). Primary outcomes assessed were pre-operative pain and use of rescue analgesics. Secondary outcome was cognitive impairment. We present a bias assessment, a meta-analysis and a grading of certainty of evidence.

RESULTS

We included five trials (n = 254), where participants received FNB 30 minutes or more prior to surgery; all were judged as having high risk of bias. All studies found significantly decreased pain scores at least once in the intervention group compared to the control group. Meta-analysis on the primary outcome of pain showed significance. Mean difference was -2.13 point (in cm) (CI:-3.53,-0.72) on visual analogue scale in the intervention group, but is judged low on certainty.

CONCLUSIONS

The quantity of evidence supporting pre-operative single-shot FNB for hip fractures is very low, and the certainty of evidence supporting pre-operative single-shot FNB for hip fractures is low. No studies using ultrasound guided technique were identified. Data on non-ultrasound guided FNB's suggest a decreased pain score compared to the use of systemic analgesia.

Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 1: The problem; nomenclature; delirium and postoperative neurocognitive disorder; and the role of cardiac surgery and anesthesia

The association with cardiac surgery with cognitive decline was first reported in the 1960s after the introduction of coronary artery surgery. The incidence in cognitive decline was thought to be more after cardiac surgery, especially with the use of the cardiopulmonary bypass. Anesthesia and surgery are both associated with cognitive decline but many other factors appear to contribute its genesis. On-pump surgery, microembolization during manipulation of the heart and great vessels, temperature changes, pH changes, and altered cerebral perfusion, during cardiac surgery, have all been blamed for this. Postoperative cognitive decline is associated with poor clinical outcomes and higher mortality. Several studies have been conducted in the last decade to determine the genesis of this malady. Current evidence is absolving cardiac surgery and anesthesia to be the primary causes per se of cognitive dysfunction.

["Emergency anesthesia" in geriatric patients]

BACKGROUND

The share of elderly patients undergoing emergency surgery is constantly increasing. Their postoperative outcome remains poor, even if surgery itself is survived in the short or medium term.

OBJECTIVES

Important aspects of anesthesiologic care for older emergency patients based upon recent literature and guideline recommendations are presented.

METHODS

Selective review of the literature, considering national and international guidelines, meta-analysis and Cochrane reviews.

CONCLUSION

Anesthesiologic care can significantly influence the perioperative outcome of elderly emergency surgery patients. In this context, emergency anesthesiology exceeds mere anesthesia itself and applies to the overall perioperative management.

[Differential diagnosis of neurological conditions in cardiac patients on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries]

The review is devoted to analysis of current trends in interdisciplinary approach to the differential diagnosis of patients' conditions on the first day after cardiac, ascending aortic and aortic arch surgery and repair of internal carotid arteries (neurological disorders, delirium, cognitive dysfunction, psycho-emotional disorders, postoperative sedation). This approach is valuable to determine the prognosis and timely treatment. The basic concepts reflecting the discussion between neurologists, cardiovascular surgeons, anesthetists, radiation diagnostics specialists and rehabilitators are summarized. The authors concluded that timely and correct differential diagnosis of the states on the first postoperative day using current tests and interdisciplinary approach to the treatment of patients with postoperative impaired consciousness or neurological/psycho-emotional dysfunction can improve their quality of life and efficiency of medical care.

Improvement of perioperative care of the elderly patient (PeriAge): protocol of a controlled interventional feasibility study

INTRODUCTION

Geriatric patients have a pronounced risk to suffer from postoperative complications. While effective risk-specific perioperative measures have been studied in controlled experimental settings, they are rarely found in routine healthcare. This study aims (1) to implement a multicomponent preoperative and intraoperative intervention, and investigate its feasibility, and (2) exploratorily assess the effectiveness of the intervention in routine healthcare.

METHODS AND ANALYSIS

Feasibility and exploratory effectiveness of the intervention will be investigated in a monocentric, prospective, non-randomised, controlled trial. The intervention includes systematic information for patients and family about measures to prevent postoperative complications; preoperative screening for frailty, malnutrition, strength and mobility with nutrient supplementation and physical exercise (prehabilitation) as needed. Further components focus on potentially inadequate medication, patient blood-management and carbohydrate loading prior to surgery, retainment of orientation aids in the operating room and a geriatric anaesthesia concept. Data will successively be collected from control, implementation and intervention groups. Patients aged 65+ with impending surgery will be included. A sample size of 240, n=80 per group, is planned. Assessments will take place at inclusion and 2, 30 and 180 days after surgery. Mixed-methods analyses will be performed. Exploratory effectiveness will be assessed using mixed segmented regressions. The primary endpoint is functional status. Secondary endpoints include cognitive performance, health-related quality of life, length of inpatient stay and occurrence of postoperative complications. Feasibility will be assessed through semi-structured interviews with staff and patients and quantitative analyses of the data quality, focussing on practicability, acceptance, adoption and fidelity to protocol.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the Helsinki Declaration and to principles of good scientific practice. The Ethics Committee of the Medical Association Hamburg, Germany, approved the protocol (study ID: PV5596). Results will be disseminated in scientific journals and healthcare conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03325413.

Preoperative Serum Albumin Level As A Predictor Of Postoperative Pneumonia After Femoral Neck Fracture Surgery In A Geriatric Population

Purpose

Femoral neck fracture usually occurs in the geriatric population. Postoperative pneumonia (POP) is known to be devastated, and it is the most frequent complication among patients receiving surgical treatment for femoral neck fractures. However, whether patients who have hypoalbuminaemia are susceptible to the development of POP is a serious concern, although it has not been investigated. We attempted to investigate the association between newly developed POP and hypoalbuminaemia and to identify whether hypoalbuminaemia is an independent risk factor for POP after femoral neck fracture in geriatric population.

Patients and methods

We retrospectively reviewed the records from the first 30 days after surgery of patients who were ≥65 years of age and who had a femoral neck fracture treated with surgery between January 2018 and December 2018 at the Honghui Hospital, Xi’an Jiaotong University. Patients were divided into two groups based on whether they did or did not experience POP, and their clinical characteristics were compared. Binomial logistic regression was used to identify potential risk factors of POP by analysing demographic factors, preoperative comorbidities, laboratory results, and surgical factors.

Results

A total of 720 patients were included in the analysis, and 54 patients experienced POP. The incidence of POP after surgical treatment for a femoral neck fracture in this geriatric population was 7.5%. In addition, patients with POP had significantly longer hospital stays than patients without POP. The binary logistic regression analysis revealed that preoperative hypoalbuminaemia [odds ratio =5.187, 95% confidence interval (CI): 2.561–10.506, P<0.0001], COPD (OR =3.819, 95% CI: 1.247–11.701, P=0.019), prior stroke (OR =3.107, 95% CI: 1.470–6.568, P=0.003) and the time from injury to surgery (OR =1.076, 95% CI: 1.034–1.119, P<0.0001) were predominant and independent risk factors associated with POP after femoral neck fracture in this geriatric population.

Conclusion

The current study revealed that among a geriatric population admitted for femoral neck fracture surgery, preoperative hypoalbuminaemia was a predictor of POP, followed by COPD, prior stroke and the time from injury to surgery. Thus, patients who undergo femoral neck fracture surgery and have preoperative hypoalbuminaemia should receive additional monitoring and perioperative care.

Determinants of Perioperative Outcome in Frail Older Patients

BACKGROUND

Older patients are undergoing surgery in increasing numbers. Frailty is a key risk factor associated with higher rates of complications and mortality, longer hospital stays, and functional impairment.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed, including guidelines from Germany and abroad.

RESULTS

Many studies have been published on the assessment of frailty and its consequences, but the scientific investigation of this topic and the clinical utility of the findings are made more difficult by the lack of a uniform definition and of uniform instruments for assessment. Some definitions of frailty include only physical aspects, while others encompass cognitive, emotional, and social factors as well. Despite this variability, the assessment of frailty enables better estimation of the perioperative risk so that the patient can be optimally prepared for the operation. Especially for frail elderly patients, an interdisciplinary approach is called for over the entire perioperative treatment period.

CONCLUSION

In the future, the definition of frailty will need to be standardized so that this parameter can be properly assessed and investigated in comparative studies.

Preoperative cardiac function parameters as valuable predictors for nurses to recognise delirium after cardiac surgery: A prospective cohort study

BACKGROUND

Delirium is a common postoperative complication after cardiac surgery. The relationship between delirium and cardiac function has not been fully elucidated.

AIMS

The aim of this study was to identify the association between preoperative cardiac function and delirium among patients after cardiac surgery.

METHODS

We prospectively recruited 635 cardiac surgery patients with a planned cardiac intensive care unit admission. Postoperative delirium was diagnosed using the confusion assessment method for the intensive care unit. Preoperative cardiac function was assessed using N-terminal prohormone of brain natriuretic peptide (NT-proBNP), New York Heart Association functional classification and left ventricular ejection fraction.

RESULTS

Delirium developed in 73 patients (11.5%) during intensive care unit stay. NT-proBNP level (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.01-1.52) and New York Heart Association functional classification (OR 2.34, 95% CI 1.27-4.31) were both independently associated with the occurrence of delirium after adjusting for various confounders. The OR of delirium increased with increasing NT-proBNP levels after the turning point of 7.8 (log-transformed pg/ml). The adjusted regression coefficients were 1.19 (95% CI 0.95-1.49, P=0.134) for NT-proBNP less than 7.8 (log-transformed pg/ml) and 2.78 (95% CI 1.09-7.12, P=0.033) for NT-proBNP greater than 7.8 (log-transformed pg/ml). No association was found between left ventricular ejection fraction and postoperative delirium.

CONCLUSION

Preoperative cardiac function parameters including NT-proBNP and New York Heart Association functional classification can predict the incidence of delirium following cardiac surgery. We suggest incorporating an early determination of preoperative cardiac function as a readily available risk assessment for delirium prior to cardiac surgery.

Postoperative delirium after hysteroscopy in young woman: A case report

RATIONALE

Postoperative delirium is extremely rare in young women and in minimally invasive endoscopic surgeries in gynecology and obstetrics. It greatly affects both physicians and patients. This report presents a special case of postoperative delirium after hysteroscopy in a young woman and a literature review of the associated etiology, diagnosis, and treatment.

PATIENT CONCERNS

A 39-year-old woman was admitted to the gynecology ward following irregular vaginal bleeding for 3 months and an intrauterine space-occupying lesion for 1 week. Hysteroscopy, endometrial polypectomy, and fractional curettage procedures were successfully performed; however, the patient became unresponsive after surgery.

DIAGNOSIS

Postoperative delirium.

INTERVENTIONS

Sedatives and vasoactive medicines, such as dexmedetomidine, midazolam, and dopamine were administered for maintenance treatment.

OUTCOMES

The patients gradually regained consciousness.

LESSONS

Physicians should attach importance and improvise effective clinical management strategies for postoperative delirium based on clinical specialty characteristics and related guidelines.

Intraoperative Low Alpha Power in the Electroencephalogram Is Associated With Postoperative Subsyndromal Delirium

Background

Postoperative delirium (PD) and subsyndromal delirium (PSSD) are frequent complications in older patients associated with poor long-term outcome. It has been suggested that certain electroencephalogram features may be capable of identifying patients at risk during surgery. Thus, the goal of this study was to characterize intraoperative electroencephalographic markers to identify patients prone to develop PD or PSSD.

Methods

We conducted an exploratory observational study in older patients scheduled for elective major abdominal surgery. Intraoperative 16 channels electroencephalogram was recorded, and PD/PSSD were diagnosed after surgery with the confusion assessment method (CAM). The total power spectra and relative power of alpha band were calculated.

Results

PD was diagnosed in 2 patients (6.7%), and 11 patients (36.7%) developed PSSD. All of them (13 patients, PD/PSSD group) were compared with patients without any alterations in CAM (17 patients, control group). There were no detectable power spectrum differences before anesthesia between both groups of patients. However, PD/PSSD group in comparison with control group had a lower intraoperative absolute alpha power during anesthesia (4.4 ± 3.8 dB vs. 9.6 ± 3.2 dB, p = 0.0004) and a lower relative alpha power (0.09 ± 0.06 vs. 0.21 ± 0.08, p < 0.0001). These differences were independent of the anesthetic dose. Finally, relative alpha power had a good ability to identify patients with CAM alterations in the ROC analysis (area under the curve 0.90 (CI 0.78-1), p < 0.001).

Discussion

In conclusion, a low intraoperative alpha power is a novel electroencephalogram marker to identify patients who will develop alterations in CAM - i.e., with PD or PSSD - after surgery.

Processed EEG monitoring for anesthesia and intensive care practice

Individual response to sedatives and hypnotics is characterized by high variability and the identification of a personalized dose during anesthesia in the operating room and during sedation in the intensive care unit may have beneficial effects. Although the brain is the main target of general intravenous and inhaled anesthetic agents, electroencephalography (EEG) is not routinely utilized to explore cerebral response to sedation and anesthesia probably because EEG trace reading is complex and requires encephalographers' skills. Automated processing algorithms (processed EEG, pEEG) of raw EEG traces provide easy-to-use indices that can be utilized to optimize anesthetic management. A large number of high-quality studies and the recommendations of international scientific societies have confirmed the deleterious consequences of inadequate or excessively deep anesthesia (and sedation) level. In this context, anesthesia in the operating rooms and moderate/deep sedation in intensive care units driven by pEEG monitors could become a standard practice in the near future. The aim of the present review was to provide an overview of current knowledge and debate on available technologies for pEEG monitoring and their role in clinical practice for anesthesia and sedation.

Inadequate emergence after non-cardiac surgery-A prospective observational study in 1000 patients

INTRODUCTION

The post-anaesthetic phase is most often uncomplicated, but patients may experience inadequate emergence (IE) characterized by unrest, restlessness, aggressiveness or in contrast sedation or lack of initiative. This may increase length of stay (LOS) and post-operative complications. The aim of this study was to investigate frequency, risk factors and consequences of IE.

METHODS

We conducted an observational cohort study including 1000 orthopaedic and abdominal surgical patients, screened with the Nursing Delirium Screening Scale (Nu-DESC) before induction of anaesthesia, at arrival at the post-operative care unit, and just before discharge from PACU. IE was defined as a Nu-DESC score ≥2 after surgery. Predictors included surgical procedure, type and duration of anaesthesia, age, ASA-score, sex and post-operative pain. Data were analysed during adjusted logistic regression and Wilcoxon rank sum test, the primary outcome being LOS.

RESULTS

IE occurred in 103 of 1000 patients (10.3%, 95% CI 8.6-12.3%). LOS was median 2 vs 1 day in patients with and without IE, mean difference was 1.3 (SD 6.2) days (P = 0.036). Thirty-day mortality was 2.9 vs 1.0% (P = 0.92) and admission to ICU 1.0 vs 0.9% (P = 0.66) in patients with and without IE. Significant associations to IE were found for inhalational anaesthetics (OR 2.65; 95% CI: 1.57-4.46), duration of anaesthesia ≥2 hours (OR 1.98; 95% CI: 1.14-3.44) and ASA-score ≥3 (OR 2.74; 95% CI: 1.64-4.57).

CONCLUSION

One of 10 patients had IE as defined by the Nu-DESC score, which was significantly associated with increased LOS. Longer duration of anaesthesia, inhalational anaesthesia and ASA ≥3 were significantly associated to this.

Pain Screening in the Older Adult With Delirium

BACKGROUND

In patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking.

AIM

To examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings.

DESIGN

A descriptive repeated measures design.

SETTING

Medical-surgical units in an urban tertiary care hospital.

PARTICIPANTS

Sixty-eight older adults with delirium.

METHODS

Patients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention.

RESULTS

Patients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, η_p² = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, η_p² = 0.11.

CONCLUSIONS

The PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings.

CLINICAL IMPLICATIONS

Pain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.

Impact of postoperative dexmedetomidine infusion on incidence of delirium in elderly patients undergoing major elective noncardiac surgery: a randomized clinical trial

PURPOSE

Postoperative delirium is a serious and common complication, it occurs in 13-50% of elderly patients after major surgery, and presages adverse outcomes. Emerging literature suggests that dexmedetomidine sedation in critical care units (intensive care unit) is associated with reduced incidence of delirium. However, few studies have investigated whether postoperative continuous infusion of dexmedetomidine could safely decrease the incidence of delirium in elderly patients admitted to general surgical wards after noncardiac surgery.

PATIENTS AND METHODS

This double-blind, randomized, placebo-controlled trial was conducted in patients aged 65 years or older undergoing major elective noncardiac surgery without a planned ICU stay. Eligible patients were randomly assigned to receive either dexmedetomidine (0.1 μg/kg/h) or placebo (0.9% normal saline) immediately after surgery though patient-controlled intravenous analgesia device. The primary outcome was the incidence of delirium during the first 5 postoperative days. Secondary outcomes included postoperative subjective pain scores and subjective sleep quality. The study dates were from January 2018 to January 2019.

RESULTS

A total of 557 patients were randomly assigned to receive either dexmedetomidine (n=281) or placebo (n=276). The incidence of postoperative delirium had no difference between the dexmedetomidine and placebo groups (11.7% [33 of 281] vs 13.8% [38 of 276], P=0.47). Compared with placebo group, patients in dexmedetomidine group reported significant lower numerical rating score pain scores at 3, 12, 24, and 48 hrs after surgery (all P<0.05) and significant improved Richards Campbell Sleep Questionnaire results during the first 3 postoperative days (all P<0.0001). Dexmedetomidine-related adverse events were similar between the two groups.

CONCLUSION

Postoperative continuous infusion of dexmedetomidine did not decrease the incidence of postoperative delirium in elderly patients admitted to general surgical wards after elective noncardiac surgery.

The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly

STUDY OBJECTIVE

To determine the association of preoperative delirium with postoperative outcomes following hip surgery in the elderly.

DESIGN

Retrospective cohort study.

SETTING

Postoperative recovery.

PATIENTS

8466 patients all of whom were 65 years of age or older undergoing surgical repair of a femoral fracture. Of the total population studied, 1075 had preoperative delirium. Of those with preoperative delirium, 746 were ASA class 3 or below and 327 were ASA class 4 or above. Of the 7391 patients without preoperative delirium, 5773 were ASA class 3 or below and 1605 were ASA class 4 or above. The remainder in each group was of unknown ASA class.

INTERVENTIONS

We used multivariable logistic regression to explore the association of preoperative delirium with 30-day postoperative outcomes. The odds ratio (OR) with associated 95% confidence interval (CI) was reported for each covariate.

MEASUREMENTS

Data was collected regarding the incidence of postoperative outcomes including: delirium, pulmonary complications, extended hospital stay, infection, renal complications, vascular complications, cardiac complications, transfusion necessity, readmission, and mortality.

MAIN RESULTS

After adjusting for potential confounders, the odds of postoperative delirium (OR 9.38, 95% CI 7.94-11.14), pulmonary complications (OR 1.83, 95% CI 1.4-2.36), extended hospital stay (OR 1.47, 95% CI 1.26-1.72), readmission (OR 1.27, 95% CI 1.01-1.59) and mortality (OR 1.92, 95% CI 1.54-2.39) were all significantly higher in patients with preoperative delirium compared to those without.

CONCLUSIONS

After controlling for potential confounding variables, we showed that preoperative delirium was associated with postoperative delirium, pulmonary complications, extended hospital stay, hospital readmission, and mortality. Given the lack of studies on preoperative delirium and its postoperative outcomes, our data provides a strong starting point for further investigations as well as the development and implementation of targeted risk-reduction programs.

Effects of peri-operative intravenous administration of dexmedetomidine on emergence agitation after general anesthesia in adults: a meta-analysis of randomized controlled trials

Objective

The aim of the current meta-analysis was to assess the effect of dexmedetomidine on emergence agitation (EA) and the recovery outcomes after general anesthesia in adults.

Methods

We searched the PubMed, the Cochrane Central Register of Controlled Trials, Embase, Web of Science and clinicaltrials.gov for relevant randomized controlled trials (RCTs) investigating the effects of dexmedetomidine on the EA in adults after general anesthesia compared with placebo. The primary outcome was the incidence of EA. Secondary outcomes included other recovery outcomes after general anesthesia.

Results

Twelve RCTs (842 participants) met the eligibility criteria. A conventional random-effects meta-analysis demonstrated that peri-operative intravenous dexmedetomidine could be effective for the prevention of EA [risk ratio (RR) 0.49, Trial Sequential Analysis (TSA)-adjusted 95% confidence interval (CI) 0.35–0.68, P<0.00001]. In addition, the TSA indicated that the meta-analysis for the incidence of EA reached the required information size (370). Lower number of patients receiving dexmedetomidine required analgesia (P=0.0009). Extubation time was longer (P=0.03) and hypotension (P=0.03) was more common with dexmedetomidine. Moreover, no difference was found in the other outcomes.

Conclusion

Dexmedetomidine was shown to effectively decrease the incidence of EA and to reduce postoperative analgesic requirements. Yet, other recovery outcomes including extubation time, length of PACU stay, postoperative residual sedation, hypotension, bradycardia as well as postoperative nausea and vomiting provided no data that could be used to form final conclusions.

Incidence and risk factors of PostopeRativE delirium in intensive care unit patients: A study protocol for the PREDICt study

AIM

The aims of this study are: (a) to determine the incidence of postoperative delirium (POD) among surgical intensive care unit (ICU) patients in China and identify risk factors, especially, which are modifiable and have value for developing a prediction model; (b) to develop and validate a prediction model of delirium to recognize high-risk patients in surgical ICUs; (c) to investigate the short- and long-term outcomes of delirious patients and identify the predictors of patient outcomes.

DESIGN

A single-centre prospective cohort study.

METHODS

Patients will be enrolled from three surgical ICUs in a tertiary teaching hospital. Delirium assessment and perioperative data will be collected throughout the hospitalization. Delirious patients will be followed up for 2 years. The study was approved by the ethics committee in May 2018 and was funded by the clinical research grant from Zhongshan hospital, Fudan University, Shanghai.

DISCUSSION

Developing POD can be a burden to patients both for the short- and long-term period. Due to the lack of effective treatments for POD, prevention remains the best strategy. This study will provide an effective tool for early screening of high-risk patients of POD and provide a better understanding of the aetiology and outcome of delirium.

IMPACT

In clinical practice, a prediction model will offer an effective tool for ICU nurses to assess high-risk patients, which can support them to implement preventive strategies at the early stages to targeted patients. The follow-up results will help us better understand the impact of delirium on patients' long-term outcome.

Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty: a retrospective population-based cohort study

BACKGROUND

With an ageing population, the demand for joint arthroplasties and the burden of postoperative delirium is likely to increase. Given the lack of large-scale data, we investigated associations between perioperative risk factors and postoperative delirium in arthroplasty surgery.

METHODS

This retrospective population-based cohort study, utilized national claims data from the all-payer Premier Healthcare database containing detailed billing information from >25% nationwide hospitalizations. Patients undergoing elective total hip/knee arthroplasty surgery (2006-2016) were included.The primary outcome was postoperative delirium, while potential risk factors included age, gender, race, insurance type, and modifiable exposures including anesthesia type, opioid prescription dose (low/medium/high), benzodiazepines, meperidine, non-benzodiazepine hypnotics, ketamine, corticosteroids, and gabapentinoids.

RESULTS

Among 1 694 795 patients' postoperative delirium was seen in 2.6% (14 785/564 226) of hip and 2.9% (32 384/1 130 569) of knee arthroplasties. Multivariable models revealed that the utilization of long acting (OR 2.10 CI 1.82 to 2.42), combined long/short acting benzodiazepines (OR 1.74 CI 1.56 to 1.94), and gabapentinoids (OR 1.26 CI 1.16 to 1.36) was associated with increased odds of postoperative delirium. Lower odds of postoperative delirium were seen for neuraxial versus general anesthesia (OR 0.81 CI 0.70 to 0.93) and with the utilization of non-steroidal anti-inflammatory drugs (OR 0.85 CI 0.79 to 0.91) as well as cyclooxygenase-2 inhibitors (OR 0.82 CI 0.77 to 0.89). Age-stratified analysis revealed lower odds with high versus low opioid dose (OR 0.86 CI 0.76 to 0.98) in patients >65 years. Findings were consistent between hip and knee arthroplasties.

CONCLUSIONS

In this large national cohort, we identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.

Effect of flurbiprofen axetil on postoperative delirium for elderly patients

OBJECTIVES

Proinflammatory cytokines triggered by surgery and postoperative pain are major causes of postoperative delirium (POD). This study investigated the effects of flurbiprofen axetil on POD when used for postoperative analgesia after major noncardiac surgery in elderly patients.

METHODS

Patients over 65 years old were randomly divided into two groups: the sufentanil group (S group), in which 150 μg of sufentanil was used in the patient-controlled analgesia (PCA) pump for 3 days; the sufentanil combined with flurbiprofen axetil group (SF group), in which 150 μg of sufentanil was combined with 300 mg of flurbiprofen axetil in the PCA pump for 3 days. The Confusion Assessment Method scale was used for POD evaluation. The pain intensity, side effects, and risk factors (age, gender, surgical position, and category of surgery) for POD were evaluated.

RESULTS

Ultimately, 140 patients were included. The overall incidence of POD was not significantly different between the S and SF groups. The incidence of POD was significantly lower in the SF group than in the S group among patients over 70 years (5.1% vs. 20.7%, p = 0.045, odds ratio = 0.146, 95% confidence interval = 0.020-1.041). The incidence of POD was no difference in patients classified by the category of surgery, surgical position, or gender between groups. Sufentanil and flurbiprofen axetil in the PCA pump was completely used within 72 hr. The pain intensity, consumed sufentanil dosage of the PCA, and the side effects was not different between groups.

CONCLUSIONS

Flurbiprofen axetil might reduce POD in patients over 70 years undergoing major noncardiac surgery.

POSTOPERATIVE PAIN AND STRESS RESPONSE: DOES CHILD'S GENDER HAVE AN INFLUENCE?

Surgical procedure causes multisystem stress response reactions. The aim of this study was to assess whether gender has an impact on the level of neuroendocrine response to surgical stress and intensity of postoperative pain in children undergoing inguinal hernia repair surgery, as well as satisfaction of their parents with preoperative and postoperative care. The study included 60 children aged 3-6 years, all of them the only child in the family. All children included in the study were categorized as American Society of Anesthesiologists PS Class I, and divided into two groups: group 1 composed of 30 boys and group 2 composed of 30 girls. After oral premedication with midazolam, general anesthesia with endotracheal intubation was performed in all patients. Ketorolac, 1 mg.kg^-1, was administered for postoperative analgesia. Serum cortisol was measured in all children preoperatively and postoperatively. The quality of postoperative analgesia was evaluated by Wong-Baker (FACES) scale, along with parental satisfaction. Male children who were the only child in the family had stronger neuroendocrine response to surgical stress and stronger intensity of postoperative pain. The parents of the girls expressed greater satisfaction with preoperative and postoperative care.

SF-36 scores predict postoperative delirium after surgery for cervical spondylotic myelopathy

OBJECTIVE

Cervical spondylotic myelopathy (CSM) is one of the most common causes of spinal cord dysfunction. Surgery for CSM is generally effective, but postoperative delirium is a potential complication. Although there have been some studies that investigated postoperative delirium after spine surgery, no useful tool for identifying high-risk patients has been established, and it is unknown if 36-Item Short Form Health Survey (SF-36) scores can predict postoperative delirium. The objective of this study was to evaluate the correlation between preoperative SF-36 scores and postoperative delirium after surgery for CSM.

METHODS

Sixty-seven patients who underwent surgery for CSM at the authors' institution were enrolled in this study. Medical records of these patients were retrospectively reviewed. Patient background, preoperative laboratory data, preoperative SF-36 scores, the preoperative Japanese Orthopaedic Association (JOA) score for the evaluation of cervical myelopathy, and perioperative factors were selected as potential risk factors for postoperative delirium. These factors were evaluated using univariable and multivariable logistic regression analysis.

RESULTS

Ten patients were diagnosed with postoperative delirium. Univariable analysis revealed that the physical functioning score (p = 0.01), general health perception score (p < 0.01), and vitality score (p < 0.01) of the SF-36 were significantly lower in patients with postoperative delirium than in those without. The total number of medications was significantly higher in the delirium group compared with the no-delirium group (p = 0.02). In contrast, there were no significant differences between the delirium group and the no-delirium group in cervical JOA scores (p = 0.20). Multivariable analysis revealed that a low general health perception score was an independent risk factor for postoperative delirium (p = 0.02; odds ratio 0.810, 95% confidence interval 0.684-0.960).

CONCLUSIONS

Some of the SF-36 scores were significantly lower in patients with postoperative delirium than in those without. In particular, the general health perception score was independently correlated with postoperative delirium. SF-36 scores could help identify patients at high risk for postoperative delirium and aid in the development of prevention strategies.